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Wilderness MedicineWilderness MedicineBackcountry DentistryBackcountry Dentistry
James Strohschein, DDSJames Strohschein, DDS
Assistant ProfessorAssistant Professor
UNM Division of Dental ServicesUNM Division of Dental Services
Treatment is limited:Treatment is limited:
Dentistry is an equipment Dentistry is an equipment intensive medical specialtyintensive medical specialty
Tooth MorphologyTooth Morphology
In the field you will be addressing In the field you will be addressing two primary concerns with two primary concerns with respect to the dentition:respect to the dentition:
1.1. TraumaTrauma
2.2. InfectionsInfections
TraumaTrauma
Any trauma to the dentition will produce Any trauma to the dentition will produce pulpitispulpitis::
•Temperature sensitivityTemperature sensitivity
•Percussion sensitivityPercussion sensitivity
•Palpation sensitivityPalpation sensitivity
•Acute / non-lingering painAcute / non-lingering pain
FracturesFracturesTypes:Types:1.1. Enamel / Dentinal Fractures Enamel / Dentinal Fractures (uncomplicated)(uncomplicated)
2.2. Pulpal Involvement Fractures Pulpal Involvement Fractures (complicated)(complicated)
3.3. Root Fractures – Root Fractures – Difficult to evaluate in the fieldDifficult to evaluate in the field
Note:Note:• Symptoms very for each typeSymptoms very for each type• Diagnosis is related to symptomsDiagnosis is related to symptoms
Enamel / Dentinal FracturesEnamel / Dentinal Fractures
Symptoms:• + sensitivity to cold (air / liquids)• Acute / Non-lingering
Diagnosis: Reversible Pulpitis
Treatment: Will require restoration or temporary coverage depending
on severity of pain
Pulpal Involvement FracturesPulpal Involvement FracturesSigns and Symptoms:• + sensitivity of hot and/or cold• Dull constant ache• Possible heme from the fractured tooth
Diagnosis: Irreversible Pulpitis
Treatment: • Temporary restoration• Will require endodontic therapy to alleviate
discomfort and prevent future infection
Dislocations / Mandibular FracturesDislocations / Mandibular FracturesFirst step is to evaluate occlusion:• Ask patient to bite teeth together to evaluate if teeth are
reapproximating• Evaluate for any facial paresthesia
Treatment: • Will require splinting• May attempt with perio-pack or floss• Difficult to do in the field• Future endodontic therapy will be needed• Evacuate patient ASAP for radiographic evaluation
Note: Any displaced teeth may involve bony fractures
AvulsionsAvulsionsDefinition: Complete loss of tooth
Imperative that tooth be kept moist:• Best solutions: saline, milk, mouth• If tooth dries out it can not be reimplanted• Never discard tooth! (dental evaluation, future uses)
Treatment: • Reimplant immediately (if possible)
• Rinse with water or saline but DO NOT SCRUB! - periodontal fibers important
• Will require splinting and future endodontic therapy
InfectionsInfectionsUsually a result of an existing condition
Many times difficult to diagnose:• Sinusitis can produce similar symptoms• Teeth usually sensitive to percussion and palpation
Clinical Evaluation:• Look for chronic / throbbing pain• Swelling• Draining fistula• Bad taste in the mouth• May be febrile
Dental AbscessDental AbscessEvaluation:• Related to necrotic pulpal tissue• Extends to the periodontium• Seeks path of least resistance• 90% of sinus tracts will travel to the buccal (cheek side)• Evaluate by extending the cheeks and lips
Treatment: • Oral antibiotics
Pen VK (500mg x 30)Clindamycin (300mg x 30)
• Will require endodontic therapy or extraction
Note: If symptoms do not improve within 48 hours consider evacuation of the patient
Facial CellulitisFacial CellulitisDefinition: Infections of odontogenic origin diffusing throughout facial planes
Locations:• Buccal Space
Source: Maxillary or Mandibular posterior teethEvaluation: Swollen cheek
• Submandibular SpaceSource: Mandibular teethEvaluation: Swollen under chin, may have difficultly swallowing,
can progress into neck planes and into the mediastinum if not aggressively treated
• Canine SpaceSource: Maxillary anterior teethEvaluation: Periorbital swelling, difficulty with vision
Treatment: IV antibiotics (if possible) then immediate evacuation
Other Dental Emergencies / ConcernsOther Dental Emergencies / Concerns
1. Loss of fillings
Treatment: Place temporary restorative material (Cavit)
2. Loss of crowns
Treatment: Re-cement with IRM
(Intermediate Restorative Material)
Note: Both restorative materials contain eugenol which will
provide coverage and pain relief
Field Dental KitField Dental Kit
Minimal kit:• Cavit, dental floss, Benzocaine gel (Orabase),
mouth mirror, head lamp or small flashlight
More extensive:• Dental syringe w/ anesthetic, IRM, temporary
filling carrier instrument, universal extractors and elevators